Provider Demographics
NPI:1275583908
Name:REBEIRO, EGBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:EGBERT
Middle Name:
Last Name:REBEIRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 KENNEDY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-3309
Mailing Address - Country:US
Mailing Address - Phone:731-587-3030
Mailing Address - Fax:731-587-3032
Practice Address - Street 1:143 KENNEDY DR
Practice Address - Street 2:SUITE B
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3309
Practice Address - Country:US
Practice Address - Phone:731-587-3030
Practice Address - Fax:731-587-3032
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24570207P00000X
ARE-6965207P00000X, 208600000X
TNMD 12630208600000X
TNMD-126302086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4082293OtherAETNA
TN3325272Medicaid
TN3831541OtherCIGNA
TN156656OtherBHP
TN4092729OtherBCBS
KY64771579OtherKY MEDICAID
TN32638OtherTLC
TN156656OtherBHP
KY64771579OtherKY MEDICAID